Sport Physical Form

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Sports Physical Form
Name: ______________________________________
Gender: M F
Date of Birth: ___/___/___
Father’s Name: _________________________ Daytime phone, pager, cell phone: _______________________
Mother’s Name: ________________________ Daytime, phone, pager, cell phone: _______________________
Street address: _____________________________________________________________________________
City: _________________ State: _______ Zip Code: __________ Home phone: ________________________
Alternate Emergency Contact Person: ______________________ Daytime phone: _______________________
Please indicate MEDICAL ALERTS such as allergic reactions, contact lenses, etc.: ______________________
__________________________________________________________________________________________
Medical History:
Athletes and parents: This health record is a critical element in the determination of an athlete’s risk of injury in sports.
Please take the time to read and answer all questions before seeing a physician for the athlete’s physical examination.
1. Has anyone in the athlete’s family (grandparents, mother, father, brother, sister, aunt,
YES
NO
Don’t Know
uncle) died suddenly before age 50?
2. Has the athlete ever stopped exercising because of dizziness or passed out during exercise?
YES
NO
Don’t Know
3. Does the athlete have asthma (wheezing), hay fever, or coughing spells after exercise?
YES
NO
Don’t Know
4. Has the athlete ever had a broken bone, had to wear a cast, or had an injury to any joint?
YES
NO
Don’t Know
5. Does the athlete have a history of concussion (getting knocked out)?
YES
NO
Don’t Know
6. Has the athlete ever suffered a heat-related illness (heat stroke)?
YES
NO
Don’t Know
7. Does the athlete have a chronic illness or see a doctor regularly for any particular problem?
YES
NO
Don’t Know
8. Does the athlete take any medication(s)?
YES
NO
Don’t Know
9. Is the athlete allergic to any medications or bee stings?
YES
NO
Don’t Know
10. Does the athlete have only one of any paired organs? (Eyes, ears, kidneys, testicles, ovaries) YES
NO
Don’t Know
11. Has the athlete had an injury in the last year that caused the athlete to miss 3 or more
YES
NO
Don’t Know
consecutive days of practice or competition?
YES
NO
Don’t Know
12. Has the athlete had surgery or been hospitalized in the past year?
YES
NO
Don’t Know
13. Has the athlete missed more than 5 consecutive days of participation in usual activities
YES
NO
Don’t Know
because of illness, or has the athlete had a medical illness diagnosed that has not been
resolved in the past year?
14. Are you, the athlete, worried about any problem or condition at this time?
YES
NO
Don’t Know
Please give details on any “YES” answer from the above health history.
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________

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